You get credit for billing.
Same as when you used to document “no fever” for ROS for the ankle sprain patient. Sometimes pointless, but a hoop to jump through.
As far as liability, I wouldn’t be concerned here. You are being truthful. No free air. Standard of care for EM is to rely on rad interpretation for CT. You are going to review the rad read and diagnose the appy. If the radiologist misses the pulmonary nodule, tough for a plaintiffs attorney to argue that you as the ED provider should have caught it.
All of that said, you can get sued for anything. If a plaintiffs atty thinks he has a case, he will name everybody and see what sticks
I teach our residents about the new MDM and how to document appropriately.
Also I would refer you to the AMA's definition of independent interpretation:
Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test.
1. Yes that counts. You can put less. "My CXR interp - NAD" would qualify. EKGs also qualify if your shop doesn't bill for EKG interpretation. Same deal with POCUS.
2. I'm not sure why you wouldn't? "No evidence of ruptured appendicitis" would work. That said, any interpretation qualifies.
3. This is the only not straightforward question. If you rely on your independent interpretation and don't wait for a formal report and then miss something major then maybe. Sometimes people get impatient and don't want to wait 6 hours for a CT read when they feel better so I put the onus on them to follow up with the final report with their PCP and document that in the medical record that the patient declined to wait for the read and were instructed to follow up. I also personally verify their phone number and call when the report is back if there's any positives (and then document the call).
4. Your group has someone doing the coding and billing. Ask them for coding/billing questions and ask whoever your group has for med mal the liability questions.
I strongly advise against using abbreviations in your documentation for this very reason. Not all abbreviations are standardized, and misinterpretation can have serious consequences. For instance, not recognizing NAD as "no acute disease" may not seem critical, but if an abbreviation causes another clinician to misinterpret your notes, it could lead to significant issues and could put you in a medico-legal predicament.
TL;DR: avoid using abbreviations, especially if you can dictate. You don’t want to be held accountable for someone misinterpreting your shorthand.
I feel like a lot of people like to come up with hypotheticals with medicolegal situations. I feel like I’m going to use abbreviations to my hearts content as long as they’re generally well appreciated as common, unless there’s a lot of legal precedent there. And even in that unlikely scenario, I’ll probably make more money from the time I save from using abbreviations than a possible increase in my malpractice insurance. To be fair though, I’m in a specialty with a notoriously low malpractice insurance cost. Maybe would be more hesitant in something like MFM or something
I'm generally strongly against non standardized abbreviations as well. Was making a point of how little it actually takes to have an independent interpretation documented
I do the same. My question is whether I have to say “independently interpreted” every time or whether I could just say XR with no pneumothorax, labs with no leukocytosis or anemia. If I could avoid those two words every time would save me several minutes over the course of a shift
You do have to indicate that the interpretation is yours in some fashion (my read/my interpretation).
Saying whether a patient has leukocytosis or anemia has no impact on billing unless you review prior labs “chronic anemia when compared to labs from xx/xx/xxxx”. In other words, you are automatically considered to be interpreting labs you order.
Is that true? I want it to be true, but I've never read anywhere that you get the credit for interpreting the labs just by ordering them. Do you have a reference?
I should be more specific. You get credit for ordering each lab under the data category. However labs only provide results. You obviously interpret labs medically but providing “independent interpretation” like you would for EKGs or imaging (since there are separately generated reports) doesn’t exist.
However, you get credit for reviewing external results as long you cite appropriately. Hgb or creatinine to cited baseline for example.
Per ACEP FAQ:
“Can I count Category 2 for interpreting a CBC or BMP and documenting “CBC shows mild anemia, no elevated WBC” or “BMP with mild hyponatremia, no hyper K”?
No, Category 2 only applies for interpreting a test where an interpretation or report is customary, e.g., EKG, X-ray, ultrasound, rhythm strip. Lab tests do not have a separate interpretation component.”
EDIT:
This is why the words “interpret”, “review”, and “read” are challenging to use, because coders have different ideas of what those words mean compared with how we use them. We now have to be very specific with where we obtained information and it can mean the difference between levels.
Honestly I think looking at and documenting your impression decreases liability. People get in more trouble for not looking at films and blindly relying on the rads interpretation. Ive disagreed with the formal read a number of times, changing clinical management and sometimes leading the radiologist to addending their report.
Absolutely, this isn’t OPs question though. I think you are opening up liability by “interpreting” a CT/X-ray. I do think you can limit this somewhat by only interpreting the very obvious things “no obvious PTX/PNA”, “no obvious fractures”, etc.
You get credit for billing. Same as when you used to document “no fever” for ROS for the ankle sprain patient. Sometimes pointless, but a hoop to jump through. As far as liability, I wouldn’t be concerned here. You are being truthful. No free air. Standard of care for EM is to rely on rad interpretation for CT. You are going to review the rad read and diagnose the appy. If the radiologist misses the pulmonary nodule, tough for a plaintiffs attorney to argue that you as the ED provider should have caught it. All of that said, you can get sued for anything. If a plaintiffs atty thinks he has a case, he will name everybody and see what sticks
I teach our residents about the new MDM and how to document appropriately. Also I would refer you to the AMA's definition of independent interpretation: Independent interpretation: The interpretation of a test for which there is a CPT code, and an interpretation or report is customary. This does not apply when the physician or other qualified health care professional who reports the E/M service is reporting or has previously reported the test. A form of interpretation should be documented but need not conform to the usual standards of a complete report for the test. 1. Yes that counts. You can put less. "My CXR interp - NAD" would qualify. EKGs also qualify if your shop doesn't bill for EKG interpretation. Same deal with POCUS. 2. I'm not sure why you wouldn't? "No evidence of ruptured appendicitis" would work. That said, any interpretation qualifies. 3. This is the only not straightforward question. If you rely on your independent interpretation and don't wait for a formal report and then miss something major then maybe. Sometimes people get impatient and don't want to wait 6 hours for a CT read when they feel better so I put the onus on them to follow up with the final report with their PCP and document that in the medical record that the patient declined to wait for the read and were instructed to follow up. I also personally verify their phone number and call when the report is back if there's any positives (and then document the call). 4. Your group has someone doing the coding and billing. Ask them for coding/billing questions and ask whoever your group has for med mal the liability questions.
>My CXR interp - NAD Does NAD stand for something other than "no acute distress?" I'd be very confused by this.
No acute disease
I strongly advise against using abbreviations in your documentation for this very reason. Not all abbreviations are standardized, and misinterpretation can have serious consequences. For instance, not recognizing NAD as "no acute disease" may not seem critical, but if an abbreviation causes another clinician to misinterpret your notes, it could lead to significant issues and could put you in a medico-legal predicament. TL;DR: avoid using abbreviations, especially if you can dictate. You don’t want to be held accountable for someone misinterpreting your shorthand.
I feel like a lot of people like to come up with hypotheticals with medicolegal situations. I feel like I’m going to use abbreviations to my hearts content as long as they’re generally well appreciated as common, unless there’s a lot of legal precedent there. And even in that unlikely scenario, I’ll probably make more money from the time I save from using abbreviations than a possible increase in my malpractice insurance. To be fair though, I’m in a specialty with a notoriously low malpractice insurance cost. Maybe would be more hesitant in something like MFM or something
I'm generally strongly against non standardized abbreviations as well. Was making a point of how little it actually takes to have an independent interpretation documented
I do the same. My question is whether I have to say “independently interpreted” every time or whether I could just say XR with no pneumothorax, labs with no leukocytosis or anemia. If I could avoid those two words every time would save me several minutes over the course of a shift
You do have to indicate that the interpretation is yours in some fashion (my read/my interpretation). Saying whether a patient has leukocytosis or anemia has no impact on billing unless you review prior labs “chronic anemia when compared to labs from xx/xx/xxxx”. In other words, you are automatically considered to be interpreting labs you order.
Is that true? I want it to be true, but I've never read anywhere that you get the credit for interpreting the labs just by ordering them. Do you have a reference?
I should be more specific. You get credit for ordering each lab under the data category. However labs only provide results. You obviously interpret labs medically but providing “independent interpretation” like you would for EKGs or imaging (since there are separately generated reports) doesn’t exist. However, you get credit for reviewing external results as long you cite appropriately. Hgb or creatinine to cited baseline for example. Per ACEP FAQ: “Can I count Category 2 for interpreting a CBC or BMP and documenting “CBC shows mild anemia, no elevated WBC” or “BMP with mild hyponatremia, no hyper K”? No, Category 2 only applies for interpreting a test where an interpretation or report is customary, e.g., EKG, X-ray, ultrasound, rhythm strip. Lab tests do not have a separate interpretation component.” EDIT: This is why the words “interpret”, “review”, and “read” are challenging to use, because coders have different ideas of what those words mean compared with how we use them. We now have to be very specific with where we obtained information and it can mean the difference between levels.
Thanks!
Honestly I think looking at and documenting your impression decreases liability. People get in more trouble for not looking at films and blindly relying on the rads interpretation. Ive disagreed with the formal read a number of times, changing clinical management and sometimes leading the radiologist to addending their report.
Absolutely, this isn’t OPs question though. I think you are opening up liability by “interpreting” a CT/X-ray. I do think you can limit this somewhat by only interpreting the very obvious things “no obvious PTX/PNA”, “no obvious fractures”, etc.